Health Care Summary- Requires Health Care Provider Signature

Health Care Summary- Requires Health Care Provider Signature
This form must be signed with a Doctor's signature on Page 2. Below are the steps that need to be completed before this form can be submitted to Little Stars.
- Step 1- Fill in the required information on the form
- Step 2- Click "Preview PDF" to ensure information is accurate
- Step 3- Click "Generate Form". A copy of the form will be sent to the email address entered.
- Step 4- Print the form
- Step 5- Sign and date the form
- Step 6- Upload the completed form by visiting the secure upload here https://oriforms.jotform.com/231338605709963?jumpToPage=8
Enrollment Date at Little Stars *

MonthDayYear
Date
Child Name*

First NameLast Name
Child Date of Birth*

MonthDayYear
Date
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/ Guardian Address*

Street Address

Apartment or Unit Number

CityState / Province

Postal / Zip Code
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Date of Signature

MonthDayYear
Date
I have clicked "Preview PDF" and reviewed my form for accuracy*

YesNo
Please verify that you are human*
Should be Empty:

Signatures